Crux of the fight against addiction

Simmi Waraich

SUBSTANCE use — mainly harmful use and dependence — has emerged as a major problem all over the world and countries are grappling with policies and reforms. As such, Anirudh Kala’s book, ‘Most of What You Know about Addiction is Wrong’, is a pertinent read, not only for policymakers but laypersons as well. It will help understand the crux of the addiction war in which thousands become dependent for life and many lose their lives to opioid and alcohol use.

The book is an engrossing read with interesting historical correlates of how opium use affected Punjab and the Northeast. It points out that India is the only country to legally produce the resinous ‘gum opium’. Apart from opium and alcohol, cannabis use is culturally sanctioned and socially acceptable among many, including the Nihangs, who call it sukh-nidhan, the giver of peace and happiness.

The book describes chronologically and succinctly how poppy husk (bhuki or dode, the poor man’s opium) or raw opium use was socially acceptable and how synthetic opiates slowly took over the youth, namely codeine-containing cough syrups, diphenoxylate and dextropropoxyphene and later heroin, the most dangerous of them all.

Interspersed with anecdotes of patients, the book is personal and human. The inevitable slowing down of the economy of Punjab as landholdings decreased but aspirations remained or even grew, is linked to the drug problem in the state.

The book covers political, social and economic aspects leading to the current grim reality and societal anomie. It gives alarming figures about how the NDPS Act criminalised many Punjabi youth for drug trafficking as most interned in jails were addicts and not peddlers. In 2014, 17,084 men were arrested in Punjab; this constituted 41 per cent of all drug-related offences in India. Sadly, the war on drugs has turned into a veritable war on our youth. Jailing isolates them from their families, whereas it is a known fact that drug-dependent patients with better outcomes are those who have better social support.

Kala makes a case for ensuring easy availability of medication and treatment of drug-dependent persons arrested with small quantities rather than incarceration in prisons. The West has started doing just that after realising how harsh measures are counterproductive. After all, these are chronic illnesses where relapse is common, and many people need treatment in the form of sublingual buprenorphine/ naloxone combination or liquid methadone for years on end.

The book highlights how legal drugs such as alcohol and nicotine are little different from illegal drugs such as opium, cannabis or cocaine and how this is a manufactured social construct. However, overdose deaths and deaths due to Hepatitis C, B and complications mean that to minimise these, we can take measures such as making free syringes available widely at all health centres and understand substance dependence as a disease and treat it scientifically, and not morally.

Kala says there is enough evidence now that if you stop one drug, some other drug takes its place commonly and the amount of drug dependence remains more or less the same. So, instead of conjuring up a moral compass and trying to get people to stay abstinent, we need to be more scientific. In fact, many people on sublingual buprenorphine/naloxone combination relapse when ill-trained doctors at government-run centres cut down their supply and get them off medication. Drugs alter the brain’s circuitry, and many cannot do without some substitute. Availability of methadone and buprenorphine reduces illegal trading, deaths, jail terms and increases contribution at jobs and social integration, etc, thereby being economically sound.

One hopes that those making policies do read this important work, in particular the models of treatment where harm reduction — by making medication easily available — and social integration are the keywords. Utilising Punjab’s psychiatrists, who have a stake in treating their patients, by making licensing of OPD de-addiction centres easy and transparent, is an essential part of this. Currently, the system is opaque; many businessmen run centres that employ out-of-state psychiatrists. Threatening measures in the past led to mental health professionals backing out of treating opioid addiction due to fear of prosecution.

In the end, Kala talks about the success of liberalisation policies in countries such as Portugal. Any country that wishes to reduce drug overdose deaths, HIV, Hepatitis C, etc, needs to study these models. One hopes that a Punjabi translation would follow so that more people can access the book and its insightful contents.

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